Phillip C. Haeck

Benchmarking Outcomes in Plastic Surgery: National Complication Rates for Abdominoplasty and Breast Augmentation

Background: The authors evaluated the use of national databases to track surgical complications among abdominoplasty and breast augmentation patients. Methods: Their study population included all patients with abdominoplasty or breast augmentation in the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) and CosmetAssure databases from 2003 to 2007. They evaluated the incidence of hematoma, infection, and/or deep venous thrombosis/pulmonary embolism. Chi-square and t tests were used for the analyses. Results: The TOPS and CosmetAssure databases included 7310 and 3350 patients with abdominoplasty and 30,831 and 14,227 patients with breast augmentation, respectively. In the TOPS and CosmetAssure populations, the complication rates for abdominoplasty were 0.9 percent and 0.5 percent with hematoma (p = 0.29), 3.5 percent and 0.7 percent with infection (p < 0.001), and 0.3 percent and 0.1 percent with deep venous thrombosis/pulmonary embolism (p = 0.05), respectively. The complication rates for breast augmentation in TOPS and CosmetAssure were 0.6 percent and 0.7 percent with hematoma (p = 0.21), 0.3 percent and 0.1 percent with infection (p < 0.001), and 0.02 percent and less than 0.01 percent with deep venous thrombosis/pulmonary embolism (p = 0.31), respectively. Conclusions: Complication rates for abdominoplasty and breast augmentation were similar in TOPS and CosmetAssure, providing a measure of cross-validation. The low complication rates support the safety of these procedures when they are performed by plastic surgeons. These data should be used by individual practitioners for outcomes benchmarking.

Risks and opportunities for plastic surgeons in a widening cosmetic medicine market: Future demand, consumer preferences, and trends in practitioners' services

Background: The American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery launched a joint Cosmetic Medicine Task Force to address the growing trend of non–plastic surgeons entering the cosmetic medicine field. The task force commissioned two surveys in 2007 to determine consumer attitudes about choosing cosmetic medicine providers and to learn about the cosmetic services that plastic surgeons offer. Methods: The first survey obtained responses from 1015 women who had undergone a cosmetic procedure or were considering having one within 2 years. The second survey obtained responses from 260 members of the two societies. Results: Compared with other practitioners, plastic surgeons enjoy higher rates of satisfaction among their patients who undergo noninvasive procedures. Injectables present a particularly promising market for plastic surgeons. Half of consumers surveyed said they were very concerned about complications associated with injectables, and generally, the higher the perceived risk of the procedure, the higher the likelihood that a patient would choose a plastic surgeon to perform it. In addition, injectables were among the noninvasive treatments most frequently being considered by consumers. However, almost half of consumers said that if they had a positive experience with a non–plastic surgeon core provider for a noninvasive procedure, that physician would likely be their first choice for a surgical procedure. Conclusions: These findings suggest that plastic surgeons, and especially those who are building young practices, must expand their offerings of nonsurgical cosmetic services to remain at the core of the cosmetic medicine field.

Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery.

Summary: Despite the many benefits of ambulatory surgery, there remain inherent risks associated with any surgical care environment that have the potential to jeopardize patient safety. This practice advisory provides an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings. In conjunction, this advisory identifies several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and provides recommendations for how best to minimize these complications.

Evidence-Based Patient Safety Advisory: Liposuction

Summary: Liposuction is considered to be one of the most frequently performed plastic surgery procedures in the United States, yet despite the popularity of liposuction, there is relatively little scientific evidence available on patient safety issues. This practice advisory provides an overview of various techniques, practices, and management strategies that pertain to individuals undergoing liposuction, and recommendations are offered for each issue to ensure and enhance patient safety.

Breast implants and anaplastic large cell lymphoma: using science to guide our patients and plastic surgeons worldwide.

On January 26, 2011, the U.S. Food and Drug Administration announced a potential association between saline-filled and silicone gel–filled breast implants and anaplastic large cell lymphoma (ALCL), a rare type of cancer. According to the U.S. Food and Drug Administration press release, data reviewed by the U.S. Food and Drug Administration suggested that patients with breast implants may have a very small but significant risk of ALCL in the scar capsule adjacent to the implant.1 Through a review of the scientific literature published between January of 1997 and May of 2010, 34 unique cases of ALCL in women with both saline and silicone breast implants have been identified among up to 10 million women with breast implants. Using additional information obtained from other international regulators, scientists, and breast implant manufacturers, the U.S. Food and Drug Administration is aware of up to a total of 60 potential cases, although confirmation is pending. The full report of the preliminary findings summarized the key findings as follows2:

Evidence-based Patient Safety Advisory: Patient Assessment and Prevention of Pulmonary Side Effects in Surgery. Part 1—obstructive Sleep Apnea and Obstructive Lung Disease

Summary: Obstructive sleep apnea and obstructive lung disease may increase a patient’s risk of perioperative pulmonary complications. This practice advisory provides an overview of the preoperative steps that should be performed to ensure appropriate patient selection and the safety of patients with these conditions. Also discussed are recommendations for perioperative management and strategies for minimizing complications.

Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 2. Patient and procedural risk factors.

Summary: Several factors may increase a patient’s risk for perioperative pulmonary complications. This practice advisory provides an overview of the preoperative steps that should be performed to ensure appropriate patient selection and patient safety with regard to pulmonary complications. Procedural and patient-related risk factors are discussed, as are recommendations for perioperative management and strategies for minimizing complications.

Evidence-based patient safety advisory: malignant hyperthermia.

Summary: As more and more routine plastic surgery procedures move from the hospital to outpatient surgery facilities, plastic surgeons must be aware of the risk factors for life-threatening events that might occur in this setting. This awareness includes recognition of the signs and symptoms and the management of a rare but life-threatening condition, malignant hyperthermia. This article reviews the current understanding of the concepts pertinent to malignant hyperthermia diagnosis and treatment in the outpatient setting and current standards and recommendations for physicians and support personnel regarding malignant hyperthermia preparedness in office-based surgery and anesthesia.

Evidence-Based Patient Safety Advisory: Blood Dyscrasias

Summary: Rarely, patients with blood disorders may seek to undergo plastic surgery. Although plastic surgeons are not expected to diagnose or manage blood disorders, they should be able to recognize which patients are suitable for surgery and which should be referred to a hematologist before a procedure. This practice advisory provides an overview of the perioperative steps that should be completed to ensure appropriate care for patients with blood disorders.

Improving the evaluation and management of the ambulatory and office-based surgical patient.

Satisfaction studies have shown that patients undergoing outpatient surgical procedures found the experience to be less stressful than a hospital admission and more discrete and convenient. This is consistent with the goals of ambulatory surgical facilities, which can achieve high rates of efficiency, safety, and satisfaction, with minimal interruption to their patients’ lifestyles. Although there have been tremendous changes to the practice of medicine over the past two decades, none may have had more impact than the radical shift toward outpatient-based treatments, including operations. Even though there are millions of successful outcomes occurring in ambulatory surgical facilities every year, there continues to be the unusual outcome or adverse event that gets the attention of the public and regulators of this industry. When this occurs, questions about the safety of outpatient surgery inevitably arise, generally revolving around two issues. Was this a patient who might have had a better outcome in a hospital operating room, and were the facility and its personnel functioning as safely as possible? No one ever expects to have a negative outcome or an unfavorable incident at an outpatient facility. When this occurs, however, it is not usually just a simple mistake or a single poor decision. Incidents tend to be multifactorial; therefore, avoiding them requires complex planning, training, and surveillance. Achieving high rates of successful outcomes at an ambulatory or office-based surgical facility should be considered mandatory by those who use them. Nevertheless, to date, no one publication has addressed each of the critical issues needed to achieve this success. The American Society of Plastic Surgeons Patient Safety Committee considered this at length and then, in 2007, committed to filling that gap with this supplement to provide the most comprehensive guide to evaluating and treating the ambulatory or office-based surgery patient. In addition, the committee set out to ensure that the recommendations contained in this treatise were, for the first time, completely based on the highest levels of evidence in the literature available at the time of publication. By doing so, only those published scientific reports that were graded the most well designed and reliable were used to set forth the treatment principles in this guideline. Readers can thus be reassured that this source of information is not based on a series of opinions, a series of anecdotal findings, or poorly designed research with questionable conclusions. Only the best evidence we could find was used in writing this supplement. Delivering high-quality care consistently means making hundreds of correct decisions, large and small, every day. However, finding quickly the answers to the questions about a particular patient’s unique medical problems and how they might impact the outcome from an outpatient operation has never been easy, and with this supplement at hand, the surgeon, anesthesiologist, and nurse should be able to confront the rare, the unusual, or even the common dilemma with a basic and reliable knowledge source in an unprecedented summation that is easy to access and hard to dispute. It is a reliable reference for nearly all the challenges one might encounter when assessing an ambulatory patient, from such things as airway management in the obese patient with obstructive sleep apnea, to the perioperative treatment of hematologic conditions that previously would have been considered the realm of hospital operating rooms only, in addition to dozens of other unusual situations. With new advances in understanding